A nurse is caring for a mother who delivered vaginally 2 hours ago.Select the 4 findings the nurse should report to the provider.
Fundus midline and firm at the umbilicus.
Moderate lochia rubra with no clots.
Constant trickle of blood at the vagina.
Hemoglobin level.
Heart rate.
Correct Answer : C,D,E
Choice A rationale
A fundus midline and firm at the umbilicus is a normal postpartum finding and does not require reporting. It indicates that the uterus is contracting as expected to prevent postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra without clots is expected in the immediate postpartum period and does not need to be reported. It is part of normal postpartum bleeding as the uterus sheds its lining.
Choice C rationale
A constant trickle of blood at the vagina postpartum could indicate a laceration or retained placental fragments and should be reported to the provider for further evaluation and management.
Choice D rationale
Hemoglobin levels can provide important information about the mother's blood loss during delivery. A low hemoglobin level could indicate significant blood loss and necessitates reporting.
Choice E rationale
An abnormal heart rate in a postpartum mother could be indicative of complications such as hemorrhage or infection and should be reported to the provider for further assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Hypertonia, tachycardia, and metabolic alkalosis are not associated with necrotizing enterocolitis (NEC). NEC is characterized by gastrointestinal symptoms and signs of systemic illness.
Choice B rationale
Hypertension, apnea, and ruddy skin color are not specific indicators of necrotizing enterocolitis (NEC). NEC primarily presents with gastrointestinal symptoms and systemic instability.
Choice C rationale
Abdominal distention, temperature instability, and bloody stools are classic signs of necrotizing enterocolitis (NEC). These symptoms indicate severe inflammation and potential bowel necrosis.
Choice D rationale
Scaphoid abdomen, no residual with feedings, and increased urinary output are not characteristic of necrotizing enterocolitis (NEC). NEC typically presents with abdominal distention and feeding intolerance. .
Correct Answer is B
Explanation
Choice A rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Choice B rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Choice C rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Choice D rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.